I grew up listening to my granny saying “prevention is better than a cure”. Follow that with a career in public health, and NHS England’s Five Year Forward View is welcome reading. It makes prevention and stronger advocacy for public health powers in local government key priorities for the NHS.
Some might argue that the NHS does not have the time, energy or resources to forge an assault on prevention given the current challenges. I would argue the NHS cannot afford not to.
An investment worth making
Prevention and effective management of long-term conditions is likely to be more cost effective than treating the illness as it occurs. The Department of Health estimates that 70 per cent of the NHS budget is spent on long-term conditions, yet it is estimated that only four per cent of the total healthcare budget is spent on prevention.
From 1990 to 2010 there have been marked reductions in ischaemic heart disease, stroke and lung cancer, largely due to improvements in diagnosis, treatment and also significant reductions in risk behaviours for those conditions, including smoking. Despite improvements, these preventable diseases remain the top three causes of premature death in the UK.
In 2008, a review of 175 economic analyses of preventative interventions demonstrated that 80 per cent were under the threshold used by NICE to determine cost effectiveness, i.e. under the threshold value of £20,000 to £30,000 per quality adjusted life year (QALY). Another review found that 85 per cent of preventative interventions considered by NICE represent good value for money (under the £20,000/QALY limit), with a median cost per QALY of £365.
The review included interventions addressing smoking, excessive alcohol consumption, physical inactivity, sexually transmitted infections and substance misuse. For example, it is estimated that alcohol screening and counselling by GPs has the potential to save the NHS and criminal justice system £40m a year each. Parenting interventions aimed at those most at risk are estimated to save £9,288 per child over 25 years.
So why does the NHS not focus more on prevention?
The NHS does provide many preventative services – including cancer screening and vaccinations – but the role of the NHS providing or commissioning services has become clouded in recent years. Following the Health and Social Care Bill, commissioning responsibilities moved to local government for many public health functions including stop smoking services, alcohol and drug misuse services, and behavioural programmes to tackle obesity, prevent cancer and other long-term conditions. But public health commissioning is at risk due to cuts in local government funding. The continual squeeze on NHS budgets may also be detrimental to activities addressing prevention.
This warning has been raised before. In 2010, HM government stated “prevention has not enjoyed parity with NHS treatment, despite repeated attempts by central government to prioritise it. Public health funds have too often been raided at times of pressure in acute NHS services and short-term crises.”
How can we stop history repeating itself?
The Five Year Forward View stated that the NHS will help work to deliver Public Health England’s priorities (including tackling obesity, reducing smoking and harmful drinking, reducing dementia risk and antimicrobial resistance) and be an “activist agent of health-related social change”.
To deliver on this, NHS staff, providers and commissioners will need to work alongside public health colleagues. For example, there is evidence that hospital inpatients (with or without a mental health condition) are motivated to stop smoking; so improving stop smoking services in acute trusts, including mental health trusts could help encourage people to quit. Such a service could be seen as an unnecessary added cost, prompting questions about “who should fund it” and “who benefits from a return in investment?”
Alternatively, health professionals may need more support and encouragement to use behaviour change tools - such as “ Very Brief Advice”, taking less than 30 seconds and designed to be used opportunistically with smokers to engage them in a supported quit attempt with a trained advisor.
On a more ambitious scale, developing joined-up care for patients with long-term conditions represents another opportunity to do things differently. Rather than starting service redesign from the point of referral of a new patient, the service needs to move towards taking a population approach.
For example, in the case of a new community service for diabetic patients, this would include reaching out to local areas where there may be a high number of people living with undiagnosed diabetes, rather than just meeting the needs of those referred into the service. The “First Stop Health Bus” is already doing this in Manchester, where it focuses on health checks and prevention and early identification of diabetes.
Get such initiatives right and the potential rewards are considerable. Estimates from Public Health England suggest that if we could reduce obesity back to 1993 levels, five million cases of disease (diabetes, hypertension, cancer, myocardial infarction and stroke) could be avoided; and if UK diets matched nutritional guidelines 70,000 premature deaths could be prevented.
Granny would be pleased.
Davies A (2014) 'Prevention is better than a cure' Nuffield Trust comment, 15 December 2014. https://www.nuffieldtrust.org.uk/news-item/prevention-is-better-than-a-cure